FEMALE GENITAL MUTILATION I A HANDBOOK FOR FRONTLIME WORKERS I 3 l
TABLE OF CONTENTS
ACKNOWLEDGMENTS ...... Finding the right messages ...... 54 INTRODUCTION ...... Well-planned strategies and tailored activities ...... 58 Working with the mass media ...... 61 PART 1: WHO IS AFFECTED BY FGM? High quality training for all .....
FGM IN THE WORLD TODAY 9 ...... 111: MEASURES OF PROGRESS ...... Definitions and classifications of FGM ...... 10 A vital role for research ...... How is FGM carried out? ...... 10 Finding out what works best ...... Measuring the impact of programmes ...... 74 PART 2: WHY DO PEOPLE PRACTISE FGM?
THE SOCIAL CONTEXT ...... 13 CASE STUDIES: SOME SUCCESSFUL PROJECTS The "mental mapn ...... 14 EGYPT: Communities monitor "at risk" girls ...... 81 What the research tells us ...... 15 . . KENYA: Communities celebrate alternative Nlgerla ...... 15 coming of age ceremonies ...... 83 Somalia ...... 16 SENEGAL: Empowerment of women leads Sudan ...... 17 to ban on FGM .the TOSTAN experience ...87 Egypt ...... 18 UGANDA: The REACH Programme . celebrating cultural identity ...... PART 3: THE HEALTH CONSEQUENCES OF FGM
A DANGEROUS PRACTICE ...... 23 COMMENTS AND RECOMMENDATIONS What the research tells us ...... 23 COMMENTS AND RECOMMENDATIONS ...... 95 Immediate complications ...... 23 LIST OF ACRONYMS ...... 97 Long-term complications ...... 25 Problems in pregnancy and childbirth ...... 28 ANNEXES: Psychological and sexual consequences of FGM . . 29 1. International action ... PART 4: FGM PREVENTION PROGRAMMES: LESSONS FROM THE FIELD HIGHLIGHTED TEXT I: STRONG FOUNDATIONS ...... 35 Players in the field ...... 35 'Itvo women tell their stories ...... Laws and policies to protect women and girls ...... 37 The Inter-Africa Committee on Harmful Making FGM a mainstream issue ...... 40 Traditional Practices at work in Burkina Faso Training for health care providers ...... 41 and Ethiopia ...... 36 Coordination between anti-FGM organizations ..... 42 FGM and the law ...... 38 ...... -p- A central role for advocacy ...... 43 To pass a law or not to pass a law? ...... 39 A physician speaks out ...... 41 11: COMMUNICATION AND BEHAVIOUR Egypt's "New Horizonsn Project ...... 50 CHANGE ...... 46 The dangers of focusing on FGM as a A role for all players ...... 48 health issue ...... A focus on youth ...... 49 A focus on human rights in Egypt ...... A focus on urban elites ...... Mali fosters community decision-making A limited role for traditional excisors ...... 51 over FGM ...... Building on positive community values ...... 52 Some pitfalls to avoid ..... FEMALE GENITAL MUTILATION 1 4 1 A HANDBOOK FOR FROMTLINE WORKERS
ACKNOWLEDGMENTS
The World Health Organization (WHO) wishes to thank the following teams and collaborating institutions and organizations for the reviews on: (a) FGM programmes: Asha A. Mohamud, Nancy A. Ali and Nancy Yinger (Program for Appropriate Technology in Health (PATH); (b) socio-economic and cultural aspects: Dr Rhetta Moran, Dr Hermione Lovel, MS Zeinab Mohammed (University of Manchester) and Dr Margaret Njikam Savage (University of Douala); and (c) on the health complications: Dr Hermione Lovel, Dr Claire McGettigan, MS Zeinab Mohammed (University of Manchester)
WHO gratefully acknowledges the support provided by the WHO Regional and Country Offices for the Eastern Mediterranean and Africa, the many individuals and the network of researchers in countries who contributed to the reviews.
WHO also gratefully acknowledges the financial support of AUSaid, DFID and UNFIP for the project.
Acknowledgments to Efua Dorkenoo, Department of Women' S Health, WHO for initiating the project, coordinating key technical inputs into all the reviews and bringing together the information into one document. Thanks goes to Jillian Albertolli for administrative support. Special thanks also go to Sue Armstrong for editing of the handbook.
Design: Mr Caleb Rutherford - eidetic Photos: WHO
O World Health Organization, 2000
This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced and translated, in part or in whole, but not for sale or for use in conjunction with commercial purposes.
The views expressed in documents by named authors are solely the responsibility of those authors.
Department of Women's Health Family and Community Health World Health Organization Geneva FEMALE GENITAL MUTILATION AH~OOKFORFRONTLINE WORKERS 1 5 1
INTRODUCTION
Until relatively recently, scientists, the international organizations asking for information on their anti- community and national governments turned a blind FGM programme strategies and activities, staffing, eye towards female genital mutilation (FGM), sources of funds, target audiences, materials unwilling to tackle an issue of such extreme sensitivity. developed, evaluation, difficulties experienced and The few people who did try to investigate and lessons learnt. 102 questionnaires were returned, and challenge the practice met with such a strong and the information from 88 organizations particularly hostile reaction from communities where FGM was active in the field was analysed in depth. Subsequently, the tradition that most quickly dropped the matter. PATH researchers visited five African countries with However, a number of concerned individuals and strong programmes. These were Burkina Faso, Egypt, organisations persisted with their challenge, and their Ethiopia, Mali and Uganda. In addition to the country tireless advocacy has borne fruit. Today, there is wide visits, the researchers looked in depth at specific recognition at global and national levels of the harmful projects in Kenya and Senegal. effects of FGM and of the pressing need for systematic Aware of the fact that the elimination effort is action to accelerate the elimination of the practice. hampered by major gaps in understanding why Over the past two decades, FGM prevention communities practise FGM and what effects the programmes have been established in most countries different types have on health, WHO also where this is practised. They are working today at the commissioned literature reviews of the social, level of policies and laws as well as at the grassroots economic and cultural context of FGMZ,and its health among communities where FGM is the tradition. consequences3from teams at Manchester University. What strategies have these programmes used? What The purpose of this handbook is to share with have been their strengths and weaknesses? And what readers the key findings of these research projects. The have they learnt from experience that would be useful aim is to increase the effectiveness of prevention to others in the field? In order to answer these campaigns at all levels by increasing understanding of questions and to identify the actions and ideas that the practice, and by identifying what does and does not should be given priority support, the World Health work in the field and why. The handbook is intended Organization (WHO) commissioned the Program for primarily for non-governmental organizations (NGOs) Appropriate Technology in Health (PATH) to carry out committed to the elimination of FGM, and for others a review1 of anti-FGM programmes operating mostly working at the frontline with communities that practise in countries in Africa. it, for example health service personnel. But it should The review consisted of a detailed questionnaire be of interest, also, to those responsible for policy- sent out to 365 national and international making in this field at national and international levels.
' "Female Genital Mutilation. Programmes to date: what works and what doesn't. A review': The original report, ref. WHOICHSIWMH199.5, can be obtained from the Department of Women's Health at WHO, Geneva. ''!A framework for the analysis and collation of primary data on the sodo-economic-culturalaspects of female genital mutilation". (Unpublished report), Department of Women's Health, WHO, Geneva. ' "A systematic review of research on health complications following female genital mutilation including sequelae in childbirth",The original report, ref. WHO/FCH/WMH/OO.Z, can be obtained from the Department of Women's Health at WHO, Geneva. FEMALE GENITAL MUTILATION 1 6 1 A HAND.ooK m FRONT,,.. ,ME, I
The handbook is divided into four parts:
Part 1 discusses what is known about the extent of FGM and where it is practised today:
Part 2 looks at the attitudes and beliefs that underpin FGM;
Part 3 looks at the health consequences associated with the different types of FGM;
Part 4 describes existing anti-FGM programmes in selected countries, their activities, strengths and weaknesses, and discusses lessons learnt.
The handbook is presented in such a way that the different sections or subject areas can be used separately, if desired, for reference, or teaching purposes, or photocopying. FOREWORD
100-140 million women and girls are estimated to have on chiien, on the psychosexual impact on women, or undergone some form of female genital mutilation on how to care for those who experience these problems. (FGM). FGM can have serious health consequences Notwithstanding the limitations posed by gaps in and is of great concern to the World Health existing knowledge, FGM prevention programmes Organization (WHO). In addition to causing pain and have been established over the past two decades in suffering, it is a violation of internationally accepted most countries where it is practised. Anti-FGM human rights. WHO'S governing bodies have adopted campaigners have been working to change policies a number of resolutions urging Member States to and laws, as well as at the grassroots level among establish clear national policies to end traditional communities where FGM is the tradition. What practices that are harmful to the health of women and strategies have these programmes used? What have children and have requested that WHO strengthen its been their strengths and weaknesses ? And what have technical support and other assistance to the countries we learned from experience that would be useful to directly concerned. others in the field? What do the available research data WHO has consistently and unequivocally advised tell us about the reasons why communities practise that female genital mutilation, in any of its forms, FGM, and the effects the different types of FGM have should not be practised by any health professional in on the health of women and girls? any setting, including hospitals or other health This handbook, which addresses these questions, is establishments. dedicated to the millions of women and girls who have Although much has been achieved over the past two undergone FGM and who continue to suffer the decades in lifting the veil of secrecy surrounding FGM, consequences of this practice. The authors have the elimination effort continues to be hampered by lack carefully reviewed research that will be useful to health of information. There are still major gaps in knowledge professionals, non-governmental organizations and about the extent and nature of the problem and the policy makers in advocating for technically sound kinds of interventions that can be successful in policies and approaches to discourage this practice. It eliminating it. Moreover, although there is a growing is hoped that lessons learned from the research body of data on the physical consequences, little sound findings will help to increase the effectiveness of the research has been conducted on the psychological effects current effort to eliminate FGM.
Dr Olive Shisana Executive Director Family and Community Health World Health Organization
FEMALE GENITAL MUTILATION A HANDBOOK FOR FRON.,NE wwms 1 9 1
FGM IN THE WORLD TODAY
Because of the sensitivity of the issue, comprehensive countries will adopt it also to generate reliable figures. data on the numbers of girls and women affected by On the basis of available information it is estimated FGM in different countries are extremely scarce and that 100 - 140 million girls and women have undergone vary greatly in quality and reliability. Sudan was the some form of female genital mutilation. It is also first country, in 1979, to undertake a systematic estimated that each year a further 2 million girls are at nationwide survey of the practice, and is the only risk from the practice. Most of the females affected live country able to provide comprehensive and reliable in 28 Afiican countries, and a few in the Middle East data over time. More recently, Ivory Coast, Central and Asia. Today, however, increasing numbers of girls African Republic, Egypt, Eritrea, and Mali have used and women who have suffered FGM can be found in their National Demographic and Health Surveys to Europe, Australia, New Zealand, Canada and the United gather information on FGM. A module has been States of America, mostly among immigrants from developed for this purpose and it is hoped other countries where FGM is the tradition.
Current estimates of female genital mutilation in Africa
I country Female Prevalenceb Number Country Female Prevalenceb Number I populationa population' I
Benin Kenya Burkina Faso Liberia Cameroon Mali Central African Rep. Mauritania Chad Niger Cote dlvoire Nigeria Democratic Republic Senegal of the Congo Sierra Leone Djibouti Somalia EgY Pt Sudan Eritrea Togo Ethiopia Uganda Gambia United Republic Ghana of Tanzania Guinea Guinea-Bissau
The world's women. New York, NY, United Nations, 1995 (37). Prevalence expressed as a percentage. Prevalences for Central African Republic, CBte d'Ivoire, Egypt, Mali and Sudan from Demographic and Health Survey results. Worldpoputation prospects: the 1994 revision. New York, NY, United Nations, 1994 (38). FEMALE GENITAL MUTILATION 1 10 1 A HANDBOOK FOR FRONTLlNE WORKERS I
Definition and classifications of ash, herb mixtures, porridge or cow dung, and the girl's FGM (WHO, 1995) legs may be bound together until it has healed. Female genital mutilation constitutes all procedures In some countries, more affluent families seek the which involve the partial or total removal of the services of medical personnel in an attempt to avoid external female genitalia or other injury to the female the dangers of unskilled operations performed in genital organs, whether for cultural or any other non- insanitary conditions. However, the medicalization of therapeutic reasons. FGM, which is willful damage to healthy organs for non-therapeutic reasons, is unethical and has been Type I: Excision of the prepuce with or without consistently condemned by WHO. excision of part or all of the clitoris. The age at which girls are subjected to FGM varies Type 11: Excision of the prepuce and clitoris together enormously, and is often flexible even within with partial or total excision of the labia rninora. communities, either because it is not tied to any Type 111: Excision of part or all of the external particular ceremony, or because people's belief in its genitalia and stitchingtnarrowing of the vaginal ceremonial significance has died away. The procedure opening (infibulation) may be carried out when the girl is newborn, during Type IV: Unclassified: Includes pricking, piercing childhood, adolescence, at the time of marriage or or incision of the clitoris andlor labia; stretching of during her first pregnancy. In some cultures, a woman the clitoris andlor labia; cauterization by burning is re-infibulated (re-stitched) following childbirth as a of the clitoris and surrounding tissues; scraping matter of routine. (angurya cuts) of the vaginal orifice or cutting (gishiri cuts) of the vagina; introduction of corrosive substances into the vagina to cause bleeding, or herbs into the vagina with the aim of tightening or narrowing the vagina; any other procedure which falls under the definition of FGM given above.
How is FGM carried out?
FGM is carried out using special knives ,s c1ssors, ' razors, or pieces of glass. The operation is usually performed by an elderly woman of the village specially designated this task, or by a traditional birth attendant (TBA). Anaesthetics are rarely used and the girl is held down by a number of women, frequently including her own relatives. The procedure typically takes 15 to 20 minutes, depending on the skill of the operator and the amount of resistance put up by the girl. The wound is dabbed with anything from alcohol or lemon juice to
FEMALE GENITAL MUTILATION A wvmocx w.owura wow= 1 13 1
THE SOCIAL CONTEXT
The "mental map" blind anyone assisting her in childbirth, to cause the The origins of FGM are impossible to establish, death of her baby or else physical deformity or madness; though it is known from archeological evidence to be and to cause the death of husbands and fathers. centuries old. Moreoever, it has been practised in some Psycho-sexual reasons for FGM focus on the ill form by the natives of every continent at some point effects that will be suffered by the girl, her family, in time. potential husbands and society in general if her In communities where FGM is the tradition, the external genitals are not removed. The unexcised girl is practice is so deeply rooted in the social fabric that few believed to have an over-active and uncontrollable sex people question where it started or why. It is supported drive so that she is likely to lose her virginity by a whole range of beliefs, values, myths, superstitions prematurely, to disgrace her family and damage her and codes of behaviour that reinforce one another and chances of marriage, and to become a menace to all are integral parts of the "mental map" people use to men and to her community as a whole. guide them through life. This mental map gives individ- In addition to the range of beliefs and perceptions uals an idea of where they stand in relation to others; it that support FGM, women and girls are subjected to draws the boundaries between men and women, young powerful social pressures to ensure they continue the people and old, and directs their behaviour towards practice. Typically, women who are not excised are each other. Everyone carries a mental map that serves considered unsuitable for marriage. A woman these purposes, and people of the same culture generally discovered to be unexcised at the time of her marriage have similar mental maps. However, these are not fixed: may face immediate divorce, or forcible excision. they vary and change over time under the influence of When their turn comes for excision, girls may be education, life experiences, contact with other cultures, sworn to secrecy so that the horror and pain of the exposure to the media, and other such forces. experience are not discussed with others, especially The mental maps of people who practise FGM unexcised women. Moreover, girls who are unexcised present them with powerful reasons why the clitoris and are often stigmatised. They may be jeered at as being other external genitalia of girls and women should be unclean and smelly, ridiculed in songs and poems, removed. At the core of the map are the religious, threatened with punishment by God, or told they will sociological, hygienic and aesthetic reasons. According provoke the wrath of their ancestors and other spirits to these, a woman's external genitals are ugly and dirty, While the overall mental map is similar in most of and will continue to grow ever bigger if they are not cut the countries that practise FGM, some reasons are more away. They are believed to make women spiritually prominent in certain countries than others. For unclean. And some people believe that unless her example, some Muslim countries tend to associate the clitoris is removed, a girl will not become a mature practice with tradition as well as with Islam. In some woman - or even perhaps a full member of the human societies, the emphasis is on the "rite of passage" - or race. Among the myths associated with FGM is the transition - from childhood to adulthood. In others, the belief that a woman's external genitals have the power to mythological aspects are considered most significant. FEMALE GENITAL MUTILATION 1 l41 A H+wmooK moNnw woRKms
WHY THE PRACTICE OF FGM CONTINUES: THE MENTAL MAP FEMALE GENITAL MUTILATION I A HANDBOOK FOR FRONlUNE WORKERS I1 5 1
The temptation for anti-FGM programmes to note marked tribal difference in the customs and simplify matters, and to address individual aspects of beliefs related to FGM. They show that parents are the the mental map rather than the whole picture, is most important decision makers regarding excision for strong. But it is also a root cause of failure to stop the the girls of the household. Whether the primary practice. In the real world, the different elements of the decision maker is the mother, the father, or both mental map that support FGM are interwoven and parents equally, depends greatly on the tribe they mutually reinforcing; efforts to tackle them singly lack belong to. Education level appears to influence the credibility with those who have experienced andlor decision, with one study from 1987, in which 2300 support FGM. Thus the task of prevention respondents were asked whether or not they were in programmes must be to try to understand and favour of excision for their daughters, finding the dismantle the mental map in its entirety. This is a following: painstaking task, for there is a dire shortage of reliable % Yes % No % Don, information to start off with. V- -. ..
illiterate What the research tells us (1403 people) The research study on the social, economic and primary education cultural aspects of FGM undertaken by the Manchester (537 people) 53.6 6.9 39.5
- -- University team began with a search through the social secondary education science literature for primary data - that is, first-hand (360 people) 60.5 25.5 14.0 accounts of FGM, focusing on its social context. In the short period of the project, the team identified only 40 A more recent study involving 1025 mothers, 99% such studies, a few of which dated from the 1930s, and of whom had been excised, found that those who had one from 1847. The range of issues covered by the secondary level education were more likely to have studies is limited, with information on economic refused FGM for their own daughters than those with influences, and on sexual relationships and FGM, less schooling. In this study too, the daughters of being particularly scarce. urban women were less likely to have been excised The team devised a model table for recording the than rural girls, regardless of the education levels of information given in the studies so that it can be easily their mothers, suggesting that city life had an influence extracted and compared with other such studies. The on attitudes. However, the rate of FGM was still high countries that figure most prominently in the among all groups - ranging from 98% of the rural literature are Nigeria, Somalia, Sudan, and, to a lesser girls to 87% of girls from urban families whose extent, Egypt. Despite the limited scope and mothers were well educated. geographical spread of these studies, they offer insights In many of the studies, "tradition" was given as the into the mental maps of communities that practise dominant reason for practising FGM. Some people FGM, and how time and other influences may alter the believed that flouting tradition might provoke the picture, that are widely relevant. ancestors; others that it would leave a woman vulnerable to witchcraft during childbirth, and most Nigeria said that an unexcised woman would be socially Eight of the 40 studies focus on Nigeria, and all stigmatised. The research revealed that within a FEMALE GENITAL MUTILATION 1 16 1 A HANmooK FiwNmNE
community practising FGM, there is likely to be a wide newborn. The timing of the operation seems to have range of beliefs - some held by just a few people, some been flexible in nearly all the communities studied. by the majority. For example, among people of the Though adolescence was often the preferred time, in Yoruba tribe questioned in the studies a few reality, girls could be excised at any age from a few days individuals claimed that FGM was necessary to prevent old to 20 years or more. the clitoris growing; others that it was necessary to prevent infection of the clitoris, enhance the Somalia cleanliness of the vagina, curb the sexual promiscuity The studies from Somalia span sixty years, from of women, enhance reproduction, andlor ease 1932 to 1992. They show that FGM is deeply rooted in childbirth. Many believed that FGM was necessary to tradition, though a sizeable proportion of the people protect the life of the baby during birth, though this do not perceive it as "positive culture" despite their belief was strongest among rural women - again support for it. The great majority of women are suggesting the influence of city life on attitudes and subjected to the severest form of FGM, type 111. beliefs. The data indicate that the predominant reason for A study among rural people of the Uruan tribe the practice is to protect the virginity of women until found that two thirds of the 400 respondents believed they are married, at which time in many communities that an unexcised woman posed a threat to her baby - the husband will make some public display of his that if the baby's head touched her clitoris during possession of her, such as carrying around the little delivery it would die. One third of respondents in the knife used to open her scarred vagina, or waving a same community, however, did not hold this belief. bloody cloth after consummation of the marriage. Interestingly, all the people questioned were, or had Other reasons given for the practice include the been, traditional birth attendants (TBAs) or midwives. necessity to control women's excessive sexuality, and to In this same study, around two thirds of the people enhance health, beauty and cleanliness. questioned saw FGM as a rite of passage into The practice is strongly associated with the rite of womanhood, while a third of the people did not attach passage to adulthood, with many people believing that this significance to it. the unexcised woman is caught in a state of perpetual Another study, among the Yoruba, found that FGM, immaturity. As such, she is unable to marry and have once part of a ritual that included ceremonies and children - the only paths to social status and camps for young girls about to be excised, had changed acceptance for many Somali women, especially those dramatically in modem times. The ceremonial aspects who are poorly educated. A 1991 study suggests that had largely died away and girls were most often being the genitalia of an excised woman are such a powerful excised a few days after birth, rather than as teenagers symbol of her status as an adult, and so closely tied up on the threshold of womanhood. The author of the with her own sense of identity, that many women study suggested that the reason for this was that FGM cannot imagine being able to dispense with the had become increasingly controversial, and parents and practice. Unexcised girls are mocked by their peers. excisors were keen to avoid having to negotiate with However, there is evidence from a number of other teenagers, and chose instead to make unilateral studies that people are prepared to question the value decisions about the procedure when girls were of FGM and to challenge the status quo. A 1986 survey FEMALE GENITAL MUTILATION I A HANmooK mR F~oNwNEwoww I 17 I
among medical students in Mogadishu, for example, daughters, and nearly 70% said they did not believe in found that more than one quarter of the males the practice. Of the 32 women who wanted FGM for favoured the less extreme forms of FGM, types I and their daughters, only a very small minority cited 11, for their daughters. Less than half expressed the tradition as the main reason. Nearly a quarter believed view that the practice should be maintained into the it was required by their Muslim religion, and a quarter future, though some were concerned their families favoured it for reasons of hygiene. Of the minority would oppose marriage to an unexcised girl. Female who supported the practice, many had been re- medical students were even more ready to modify or infibulated following childbirth as a matter of routine. discontinue the practice. The same study, however, They perceived virginity to be a renewable condition, found very different views among female nursing and re-infibulation to be necessary for this purpose students, who were also interviewed. 95% of them said and for the sexual pleasure of their husbands. they would have their daughters excised, and 40% of Opinions were divided on this issue: while most of the them would choose type 111. Their views were women who favoured re-infibulation claimed that it considered particularly important since, as nurses, they enhanced their own enjoyment of sex as well as that of may well be called upon to perform the operations their husbands, very many women rejected re- once they had finished their studies. By contrast, a infibulation because they felt it impaired their own 1991 study among largely uneducated women found sexual pleasure. Despite the still strong support for that, whereas two thirds of them had experienced type FGM from a minority of her sample, the author I11 themselves, less than half would want the severest concluded from her study that education, form of FGM for their own daughters. The studies did urbanisation, and the changing roles of the family were not draw any conclusions about the influence of eroding the influence of the older generation of education or city life on people's views or behaviour. women in the decision making process regarding FGM. Educated daughters were increasingly able to Sudan make up their own minds. The twelve studies from Sudan also span a half However an earlier study ( 1978) among 185 male century, from 1943 to 1994. As in Nigeria and Somalia, and female students at the University of Omdurman "traditionn is the most common reason given for FGM. showed how uneven and unpredictable these It is seen as a mark of ethnic superiority by some influences can be. All the women had experienced type tribes; though the studies suggest that in Sudan, too, I11 FGM themselves, and 91% of them supported there are many who do not consider FGM to be "good continuation of the practice, and favoured the severest traditionxther important reasons frequently given form for their future daughters as well. All respected it are that it is required by religion, or necessary for as a traditional part of their culture, nearly half cleanliness, and to preserve the chastity of girls on believed it was required by their religion, one third which the family honour depends. that it was necessary for hygienic reasons, and many However, there is evidence of attitudes and beliefs that it ensured a girl's chastity. In stark contrast, 86% changing with time. A 1994 study among high school of their male peers were against all forms of FGM, teachers found that 47 out of the 80 women believing it was an old fashioned custom, that it spoilt interviewed said they did not want excision for their women's and men's sexual pleasure, and that it was FEMALE GENITAL MUTILATION 1 18 1 A HAND~OKFOR FRONTLINE WORKERS
cruel, barbarous and dangerous. Only one of the calm their fears. Some tribes ceremonially bury the women expressed these damning views of the practice. excised flesh to ward off harm, while others take girls Interestingly, in spite of the clear opposition to FGM to the river at sunset for rituals aimed at protecting expressed by the great majority of their male peers, them from infection, bleeding and other dangers nearly all the female students believed that a woman associated with FGM. Complications suffered at the who was unexcised was unmarriageable. Clearly, this time of excision may be treated with traditional cures, was a more important consideration than any of the such as the inhalation of smoke from burning paper new ideas they had encountered at university. inscribed with texts from the Koran. The various The significance of FGM to marriage and a girl's practices described here and in other studies perceived value as a bride is underlined by a large demonstrate how supporters of FGM often cope with study from 1982. The author found that, in some the harmful effects of FGM by developing myths and communities, girls with a particularly narrow vaginal rituals to explain and treat them, rather than seeing opening, suggesting special virtue, commanded a them simply as unnecessary evil and a good reason for higher bride price than those with less severe FGM. In giving up the practice. However, more recent studies cases where the opening was too tight to enable suggest that in some communities the ceremonial penetration by her husband's penis on her wedding practices are diminishing and FGM is being performed night, the bride would sometimes be given "honour more and more often without celebration or ritual. money" by her bridegroom in recognition of her While most studies provide evidence that virtue, and it would be a source of pride to her family. influences such as education and city life are tending, According to a 1991 study, however, bride price is gradually, to undermine support for FGM, two show becoming an increasingly heavy burden on families, how they can sometimes have the opposite effect. They and in some places communities have agreed, through describe how girls and women from non-practising group discussion, to put limits to the price. tribes, such as the Nuba and Fur, who are now living in towns and villages among people who do practise FGM, are sometimes choosing to have
A 1991 study among rural women from Sudan found that the operation themselves. Most are virginity was an absolute requirement for marriage, and doing so because they look up to the virginity was synonymous with infibulation, or type Ill FGM. tribes that practise FGM and see it as a In this belief system, the hymen had no significance. status symbol. But some do so to save themselves from the ridicule and jeering of neighbours who are excised. Several studies describe the rituals surrounding FGM, which typically includes new clothes, jewellery Egypt and henna decorations for the girl to be excised, and A study from Egypt, dated 1995, gives data the giving of gifts during several days of celebration. In gathered over a ten Year period from 85 women aged some communities, girls terrified at the prospect of the 15-70 Years, 21 of whom were excis0i-s. There were operation are taken to traditional healers, who use the about equal numbers from the rural areas and from smoke of special herbs, sacred water, or amulets to the cities; half were illiterate, while one in seven had 8 FEMALE GENITAL MUTllAl'lON I A HANDBOOK FOR FRONTLINE WORKERS l 19 ]
years or more of schooling; the great majority were performed by a traditional excisor using a razor. There Muslims; all were married and they had all is no mention of celebration. Interestingly,the author experienced FGM, mostly types I and 11. notes that FGM is far more common among the urban The study found a widely held belief that the clitoris elite than is generally assumed. is responsible for a woman's sexual appetite and that it Another study from Egypt, dated 1980, gives an continues to grow unless it is removed, thus threatening indication of how many people might be involved in to overwhelm a husband's sexual capacity and the decision to excise a girl child. The researchers dangerously sap his physical strength. Some believed the interviewed women and men attending a family unexcised clitoris could grow to a size that would planning clinic over a one week period. They interfere with a man's pleasure during intercourse. Most discovered that in one case, where the mother of a girl women knew that FGM is not required by the Koran, was unexcised, the father's sister had taken the decision and religion was rarely mentioned as a reason for the for the daughters. In another case, the parents and practice. Everyone interviewed expressed the view that it brothers of the girl had decided. In a third case, the was necessary to protect a girl's virginity, and her mother, together with maternal and paternal aunts, family's honour, until the time of her marriage. Some had made the decision. And in a fourth case, an aunt also believed FGM influenced a girl's behaviour, making who had been excised herself took the decision for her her demure and submissive in public, and therefore a two nieces without their mother's consent. credit to her family. Questioned about their attitudes to FGM, about The majority of women were excised between the ten percent of the sample said it was necessary for ages of 9 and 13 years, usually during national or cleanliness. One man said he preferred a woman who religious holidays. Typically they were not prepared was clean and psychologically calm; and one woman mentally for the operation, and in more than half the said she believed FGM made girls taller, prettier and cases they were held by their mothers while it was clearer skinned. FEMALE GENITAL MUTILAT!ON 1 20 1 A HANDBOOK FOR FRONTLINE hORKERS l
KEY POINTS
The rationale for supporting FGM -the m FGM is often a powerful symbol of ethnic mental map - must be understood and identity, and sometimes a status symbol. addressed in its entirety, not broken down into separate issues. The girl who rejects FGM may be perceived by her own family as bringing them dishonour The mental map is not fixed, but changes and showing disrespect for her elders. constantly under the influences of modern lifestyles and ideas. m Even within a community that practises FGM there is likely to be a range of In communities where women have little or attitudes and beliefs, some of which may be no opportunity for economic independence, contradictory. Therefore, anti-FGM marriage is virtually the only means of messages based on generalisations will not survival. The girl who rejects excision may be credible to everyone. forfeit her chances of marriage. m Practising communities have their own, A girl's excision often has economic often mystical, ways of explaining and implications for her family, ie. in securing coping with the harm associated with FGM, and determining the size of the bride price. so new information is not being received in Sometimes this is critical to the family's a vacuum. survival. In some communities virginity, which is Not only the girl, but her whole family may highly prized, is considered to be a risk stigmatisation and social isolation if she renewable condition and women are re- does not conform to the community's stitched after childbirth as a matter of customs. routine. 1
FEMALE GENITAL MUTILATIOIW I wwmooKFOR FRoNnrNEwowas 1 23 1
A DANGEROUS PRACTICE
Female Genital Mutilation causes grave and deliberate complications identified by the papers, which span a damage to children and women. Because few records period from the 1920s to the present day, include: are kept and the practice is shrouded in secrecy, no one knows how many females die as a result, though immediate problems following FGM mortality of girls at the time of initiation is probably gynaecological and obstetric problems, including high. The range of complications associated with FGM is wide and some are severely disabling. Here too the urinary problems picture is incomplete, and no one knows what sexual and psychological problems. proportion of women suffer complications. However, it is important to remember that not all women will However, it is impossible to draw any firm have personal experience of any particular health conclusions about what proportion of girls and problem, or combination of problems. Information women subjected to FGM experience complications, campaigns that focus on health issues risk losing or about who is most likely to suffer from what and credibility with their target audiences unless this is why. The information is just too limited: Many acknowledged, and complications put into some kind complications go unreported, so health service records of perspective. For example, the timing of the that appear in the primary data are not representative. procedure - that is, whether it is carried out in infancy, When questioned by researchers, women may be childhood, adolescence or during pregnancy - has an reluctant to admit complications. Or they may be influence on the outcome. Other important factors unaware that the problems they suffer are the result of determining the outcome of an operation include the FGM, attributing them instead to some other, perhaps extent of the cutting, the skill of the operator, the supernatural, cause. As with the previous section, cleanliness of the environment and tools used, and the reference to the findings of the research project offers physical condition of the child. only valuable insights, not the basis for conclusions or generalisations. What the research tells us The main purpose of the WHO-sponsored research Immediate complications project into the health consequences of FGM was to Haemorrhage. review the primary data on complications to give an Amputation of the clitoris cuts across the clitoral idea of how frequently they occur and who is most at artery in which blood flows at high pressure. Cutting risk. The project team found a total of 474 papers and of the labia also damages arteries and veins. Not reports which they considered relevant to their surprisingly, severe bleeding (haemorrhage) is one of enquiry. 138 of these contained first hand information the most common immediate complications of on health consequences. The others were review excision. Haemorrhage may also occur after the first articles, documents with background information, or week as a result of the crust that has formed over the foreign language material still to be classified. Health wound sloughmg off, usually because of infection. 1 24 1 .FEMALE GENITAL MUTILATION I
A study of FGM in Sudan, published in 1982, practice of binding the girl's legs together which found that haemorrhage accounted for nearly one prevents drainage. Tetanus occurs when spores get into quarter of reported complications. Although it should the wound from unsterile instruments or be noted that one in four of the total sample, which contamination with faeces, and is almost always fatal. involved women from five of the six provinces of Sometimes infection becomes generalised, leading to northern Sudan, suffered no immediate complications potentially fatal blood poisoning (septicaemia), or of FGM. A 1980 study in the same country found that gangrene, which is death of surrounding tissue. 17 girls of a sample of 7505 (0.2%) who had been In the Nigerian study already mentioned, four of excised suffered severe haemorrhage as an immediate the 55 children brought to the paediatric clinic with consequence. In the great majority of cases the complications of FGM were suffering from infection. operation performed was type 111. In some, the excisor One had septicaemia, another had tetanus and the was unable to stop the bleeding and the girl went into other two had urinary infections. A study in Benin, shock as a result of blood loss as well as pain. In a from 1977, describes a woman brought into hospital as Nigerian study analysing hospital records between an emergency with septicaemia following FGM 1973-81, two out of a sample of 55 children (or 3.6%) performed in the thirty-ninth week of pregnancy. Her brought to the paediatric clinic with complications of baby was delivered by caesarian section, but died two FGM involving the amputation of the clitoris suffered days later from the infection, and the mother also died, severe bleeding. In Somalia, 20% of a sample of 300 on the fifth day following delivery from septicaemia. In women interviewed by researchers in 1995 said they a similar case from Nigeria where a woman excised had suffered haemorrhage at the time of excision. during the thirty-fourth week of pregnancy was admitted to hospital as an emergency because of severe Shock. bleeding and infection, the baby was stillborn. Of the Immediately after the operation the child may 300 women interviewed in the 1995 study in Somalia enter a state of shock as a result of haemorrhage, or already cited, 60% said their wounds had become else from the pain and anguish of the procedure since infected. In the Sudanese survey already mentioned, most operations are performed without anaesthetic. infection accounted for 151 of the 790 immediate Shock, which can be fatal, is rarely mentioned in the complications of excision. In this study, infection of literature on health consequences. However, the the wound was about ten times more common in girls Sudanese study cited above found that 3 1 of the 790 with type I11 FGM than with type 11. girls with immediate complications of FGM suffered from this condition. All had experienced the most Urine retention. extreme form of FGM, type I11 Pain, swelling and inflammation around the wound, or injury to the urethra, can make it difficult Infection. or impossible for the girl to pass urine for hours, and Infection, due to unhygienic conditions and the use sometimes days, following FGM. The frequency with of unsterilised instruments or crude tools, is common. which this complication occurs varies according to the Infection may also be caused by the use of traditional type of procedure. It often leads to infection of the medicines on the wound, and encouraged by the urinary tract. FEMALE GENITAL MUTILATION A HANDBOOK FRONnINE WORKERS 1 2 5 1
A study involving 7505 women in Khartoum, who had FGM (typically type I or 11) suffered Sudan, found that urine retention was the most persistent bleeding after sexual intercourse. None of common immediate complication of excision, the 119 women without FGM had this complaint. affecting 12% of the women. The great majority had Furthermore, of the women with FGM, 26% had undergone the severest form of FGM, type 111. Urine suffered lacerations andlor haemorrhage during the retention accounted for 84 of the 790 immediate birth of their first babies. No information is given for complications of excision in the other large Sudanese those without FGM. Three quarters of the women study. 75 cases were in girls with type I11 FGM, 17 with with FGM had been excised in early childhood. The type I1 and 2 with type I. 172 of the 790 girls had others had been excised as adolescents or young adults. difficulty passing urine, because of the pain and burning sensation in the raw wound, or because the Difficulty in passing urine. opening was constricted by stitching or swelling. The urinary opening or urinary canal may be damaged during genital mutilation or subsequent Injury to neighbouring organs. infection, resulting in difficulty andlor pain in passing As a result of careless techniques with crude tools, urine and sometimes urinary retention. failing eyesight, poor light or the struggles of the girl, A review of case records for children and women organs such as the urethra, vagina, perineum or attending a Nigerian hospital between 1973-81 for rectum may be damaged. This can lead to the complications of FGM found that 22% of the 58 cases formation of fistulae, which are false passages between had urinary retention, and 2 of the 15 adults the vagina and the bladder or the vagina and the complained of a poor urinary flow. Almost all of the rectum, through which urine or faeces leak study subjects had suffered type I1 FGM carried out in continuously. the first month of life.
Long-term complications Recurrent urinary tract infections. Bleeding. Damage to the urinary tract may result in recurrent Bleeding can occur some time after the operation if infection. This condition is particularly common in the wound becomes infected. Repeated de-infibulation infibulated women, where the normal flow of urine is (opening up the vulva to allow sexual intercourse or deflected and the perineum is constantly wet and childbirth) and re-infibulation (re-stitching following susceptible to the growth of bacteria. Sometimes the childbirth) may also cause the loss of blood which infection spreads to affect the bladder and kidneys. may, over the long-term, lead to anaemia. A study conducted at Khartoum General Hospital In one study from Sudan involving 934 patients in which all women attending the obstetrics and with FGM complications at a Khartoum hospital, 4.4% gynaecology clinic between 1962-66 were interviewed sought medical attention because of severe bleeding as and examined, found that 24% of the sample of 4024 a result of sexual intercourse. Some of the 41 cases women had urinary infections, and the infection was required resuscitation. A 1997 study from Ghana recurrent in 6% of cases. The condition was four times involving 195 women attending a rural antenatal clinic more common in women with type I11 FGM than with over a two day period found that 9 of the 76 women type 11, or no FGM. FEMALE GENITAL MUTILATION 1 26 1 .H.NDmK ,.,.,,,.. I
In the other large Sudanese study already cited, suffering from the condition. In the other large study recurrent urinary tract infection accounted for 287 of from Sudan, 244 women out of a total of 1031 with a total of 1031 long-term complications associated long term complications of FGM suffered from chronic with FGM. In this study too, those with type I11 were pelvic infection. The rate was more than 7 times higher at greatest risk, with a rate of infection more than four in women with type I11 than in women with type I1 times higher than women with type I1 FGM and about and 42 times higher than in women with type I. 32 times higher than women with type I or without FGM. Infertility. Pelvic inflammatory disease can lead to scarring of Incontinence. the fallopian tubes and infertility. However, the If damage has been caused to the urethra or rectum contribution of FGM to the high levels of infertility in during mutilation, and especially where the damage Africa is uncertain. results in a fistula (see Fistulae), the girl will leak urine The review of hospital cases involving complications andfor faeces constantly. Infibulated women may dribble of FGM type I1 in Nigeria found that infertility was the urine constantly as a result of infection under the hood reason for 6 of the 58 women attending the of scar tissue at the opening of the urinary tract. gynaecological clinic. A 1980 study in Sudan involving 7505 women, the great majority of whom had FGM Chronic pelvic infection. type 111, found an infertility rate of 2.2%. Infection from the vulva may spread internally to affect the uterus, fallopian tubes and ovaries, causing Abscesses. pelvic inflammatory disease (PID). The condition is In cases where the infection is buried under the frequently accompanied by an offensive smelling wound edges or an embedded stitch fails to dissolve, discharge, and may be caused by infection at the time an abscess can form which will usually need to be of mutilation, interference in the drainage of urine and opened surgically and drained. vaginal secretions, including menstrual blood, because The Sudan study involving 3210 women found that of scar tissue, or infection of the wound following 143 of the total sample suffered abscesses. All were in childbirth. The rate of PID in infibulated women is women with type I11 or type I1 FGM, and the three times higher than in women who have had the condition was more than 8 times more common in clitoris amputated. those with type 111. Another study from Sudan The study at Khartoum General Hospital already involving 939 patients attending a Khartoum hospital cited found that 23% of the 4024 women interviewed between 1987-9 for complications of FGM found that and examined suffered from chronic pelvic infection. 50% presented with vulva1 swelling, which frequently The condition was about 3 times more common in included infected cysts and abscesses, commonly along women with type I11 FGM than in those with type 11. the line of the scar tissue. By contrast, very low rates In most cases, excision had been performed in for abscesses were found in a 1967 study, also from childhood. However, in this study unexcised women Sudan and involving a large sample. Of the 3820 also had a high rate of chronic pelvic infection, with women with FGM interviewed and examined at an 6% of the sample of 204 women without FGM outpatient gynaecology clinic in Khartoum, only 5 FEMALE GENITAL MUTILATION mmeooK moNnwE woRKms 1 27 1
suffered from abscesses, with the rates being about the Keloids. same for those with type I11 and type I1 FGM. A keloid is an excessive growth of scar tissue which is also abnormally thickened. Many of the ethnic Dermoid cysts. groups who practise FGM are especially susceptible to These are one of the most commonly reported long- keloid formation. Keloids around the vulva are term complication of all types of FGM. A dermoid cyst disfiguring and psychologically distressing, and they forms as a result of skin tissue becoming embedded in have the effect of shrinking the genital orifice, which the scar. The gland that normally lubricates the skin will may cause problems of its own. continue to secrete under the scar and form a cyst, or The 1980 study from Sudan in which 7505 women sac, full of cheesy material. The cyst may grow to the were interviewed and clinically examined found 225 size of an orange or even bigger. Dermoid cysts are not a (3%) of the total sample had excessive scars and serious threat to physical health, but they can be keloids. The great majority of the women in this study extremely uncomfortable and distressing. had FGM type I11 which had been performed in their The frequency of this condition varies considerably childhood. One of the other large studies from Sudan from one report to another. Nineteen of the 1031 found a similar picture. 3.6%, or 107 of the 3013 women with complications of FGM in the Sudan study women with type I11 FGM suffered keloid scarring. In developed dermoid cysts, with the rate among women contrast, the other large study from Sudan, involving with type I11 FGM being five times higher than the rate 3210 women, found only l l of the 3022 women among women with type 11. In another study from willing to answer questions about complications Sudan involving 3820 women with FGM, 53 suffered suffered from keloids and painful scars - probably from dermoid cysts in the scar tissue. In this study the neuromas, involving trapped nerves. condition was about six times more common in women with type I11 FGM than with type 11.463 teenagers with Fistulae. FGM were also interviewed and examined, and 5 of the A vesico-vaginal (involving the vagina and the 236 with type I11 FGM suffered from dermoid cysts, bladder) or recto-vaginal (involving the vagina and while none of the 227 teenagers with type I FGM was rectum) fistula may develop as a result of injury affected. In the Nigerian study already cited involving 55 during mutilation, or due to de-infibulation or re- children seen in a paediatric clinic with complications infibulation, intercourse, or obstructed labour. of FGM, 14 were suffering from dermoid cysts. Of 15 Continuous leakage of urine and faeces can plague the young adults seen at the gynaecology clinic for the same woman all her life and turn her into a social outcast. study, 4 had dermoid cysts. Gishiri cutting (cutting of the vagina), classified as FGM type IV, was responsible for 13% of 1443 cases of Neuroma. vesico-vaginal fistulae reviewed in a 1983 study in If the clitoral nerve becomes trapped in scar tissue Nigeria. Here, gishiri cuts were administered for a it may develop into a neuroma, which is a tumour variety of reasons and at different stages of life, and the consisting of a mass of nerve fibres. The whole genital risk of suffering a fistula as a result rose significantly area becomes permanently and unbearably painful to with age. In another Nigerian study analysing hospital touch. records, one of the 55 children brought to the 1 28 1 .FEMALE GENITAL,.,.,,.. MUTILATION
paediatric clinic with complications of FGM involving HIVIAIDS and other bloodborne diseases. the amputation of the clitoris suffered a vesico-vaginal The risk of transmission of bloodborne organisms fistula. such as HIV and hepatitis B and C viruses may be increased for women with FGM because tearing and Calculus formation. abrasions are more likely during intercourse, or as a A calculus is a stone that forms abnormally in the body from chemicals that are in high A study from Sudan tells the story of a young concentration in certain fluids. Calculi may develop unmarried girl who was unable to menstruate properly as a result of urine or menstrual products getting as a result of infibulation. As her belly began to swell trapped in the vagina behind the wall of skin with menstrual blood that could not escape, her family created by infibulation. The only study in the series believed she was pregnant. Their suspicion was in which calculi are mentioned is from Sudan, and heightened by the lack of sign of menstruation, and the condition is described as "rare': In this study they killed her to preserve family honour. from 1967, two of a sample of 3013 women who had sought medical attention for complications of FGM type I11 were reported to have calculi. result of anal intercourse when the vagina is impossible to penetrate -but this has not been the Menstruation Mculties. subject of detailed research. Bloodborne diseases may The opening of the vagina following FGM may be also potentially be transmitted when groups of so small that menstrual blood cannot flow freely and children are simultaneously mutilated with the same may accumulate. Trapped menstrual blood is known as unsterile instrument. As yet, however, there is no haematocolpos. FGM may also result in published evidence that FGM is a major contributor to dysmenorrhoea (painful menstruation). the spread of these diseases. In the 1983 Sudan study which interviewed a cross- section of 32 10 women, 39 claimed pain during Problems in pregnancy and menstruation. 36 of women had FGM type 111, and of childbirth these 17 needed surgery to relieve the obstruction. Problems in pregnancy and childbirth are common Severe dysmenorrhoea was reported by 68 of a sample in women who have undergone type I11 FGM because of 105 Somali women who responded to a postal of the rigidity and obstruction of scar tissue. If a questionnaire, but there was no indication of how many miscarriage occurs the foetus may become trapped in of the respondents had been excised, nor of the type of the uterus or the birth canal. During childbirth, tough FGM. Dysmenorrhoea is mentioned in a number of scar tissue may prevent dilatation of the birth canal other studies as being a gynaecological complication of and obstruct labour - a condition that is hazardous FGM, but there is no indication of the frequency. and potentially fatal for both mother and baby. During prolonged obstructed labour, the mother may suffer Sexual dysfunction. lacerations, and perhaps fistulae caused by the (see below: Sexual and psychological consequences grinding of the baby's head against the walls of the of FGM) vagina, as well as severe bleeding. The baby may suffer FEMALE GENITAL MUTllATlON I A HANDBOOK FOR FRoNniNEwoRKEw I 29 I
brain damage or even die from lack of oxygen. De- Apart from the direct trauma of the event and its infibulation is necessary to prevent obstructed labour psychological effects, FGM works at a more subtle level and allow the birth of the baby. If a trained attendant to shape the self-perception and self-esteem of the is not present to cut the skin hood, de-infibulation young girl. In the longer term, women may suffer may cause haemorrhage, injury to surrounding tissues, feelings of incompleteness, anxiety, depression, chronic fistulae and infection. Often the woman andlor her irritability, and difficulty in relating to their husbands. husband demands re-infibulation following childbirth. Many such women suffer in silence, unable to express Repeated operations will weaken the scar tissue, their feelings and fears either because of taboos or besides which re-infibulation carries the same long- because they do not know how. Unfortunately too term risks as the original procedure. Evidence suggests little research has been done on the psychological that requests for re-infibulation can be reduced by impact of FGM, or its effect on child development, to offering women and their partners psychosexual establish the magnitude of the problems. counselling on the health implications. Almost all types of FGM involve damage to or Though there is a marked lack of data giving complete removal of the clitoris, which is the main figures for problems suffered in pregnancy and labour, female sexual organ, equivalent to the penis of the there is frequent mention of obstetric complications in male. The more extreme forms of FGM, which remove the studies. These include the necessity of performing all the external genitalia, leave tough scar tissue in episiotomies (cutting of the perineum to allow the baby to emerge); tears in the perineum because an episiotomy was not performed in In Sudan, women interviewed in depth about their sex time; difficulty in performing vaginal lives named the lips, neck, breasts, belly, hips and examinations during labour to monitor thighs as sensitive. All had type Ill FGM, and nine out of progress; difficulty in passing a catheter to ten claimed they had experienced orgasm at some point relieve a full bladder because of the small hole during marriage, ranging from frequently or rarely. and tough scar tissue; maternal and fetal distress because of prolonged labour; infected wounds; and sometimes stillbirth and maternal death. place of sensitive organs. Reduced sexual sensitivity, painful intercourse and the fear of pain, may lead to Psychological and sexual sexual dysfunction in both partners. Intercourse may Consequences of FGM be difficult or even impossible, which may require re- Evidence suggests that FGM is mostly remembered as an opening of the vagina with a knife or razor. However, extremely traumatic event that leaves an emotional scar for FGM does not necessarily abolish altogether the life. The psychological trauma sufkred by the child subjected possibility of sexual pleasure and orgasm. Some studies to FGM may settle deep in her subconscious mind and lead suggest that other erotic zones of the body, such as the later to disturbed behaviour. The loss of trust and confidence breasts, may become more sensitized in women with in cawgivas, such as parents and other Mymembers, who genital mutilation, particularly when the overall sexual allow the pdureto go ahead and sometimes assist during experience is pleasurable with a caring partner. the operation, is another potentially serious consequence. In a 1982 study from Somalia, 70 women and 40 FEMALE GENITAL MUTILATION 30 4 HANDBOOK FOR FRONTLINE WORKERS
men aged between 20 and 60 years were interviewed, women. Questioned about the time it took for their either individually or as part of a group, to partners to achieve penetration, three of the 2636 explorelascertain their feelings and experiences with women with type I11 FGM claimed it had taken 18 regard to FGM and sexual intercourse. All the women months, and 7 had failed altogether. About half the in the study had been excised in childhood. 81% of rest, claimed it had taken between one and 2 weeks, them had type III,6% type 11, and 13% type I. Asked and the other half between 3 and 8 weeks. The survey about their feelings prior to being excised, 40 of the 70 revealed that about 40% of the women had women said they had felt "excited and frightened", experienced tears and bleeding during first sexual another 14 said they had "mixed feelings of joy and intercourse, with the trauma being severe enough to worry", and 11 said they were "curious and eager to require medical attention in around 6% of cases. know what happened". Five of the 70 could not recall Questioned about their feelings during sex, half said their feelings. Of the 60 women who were or had been they never experienced sexual pleasure, one quarter married, 36 said they had felt anxious and frightened said they felt totally indifferent to sex, and the rest said for the first few weeks of marriage, and 20 said they they experienced pleasure frequently or only had had mixed feelings of happiness and worry. Half sometimes. The men stated that they enjoyed sex and of them said they did not enjoy sexual intercourse with believed their wives did too. their husbands, for a variety of reasons, including lack Another survey from Sudan with information on of satisfaction, pain, distaste or shyness about the the psychosexual effects of FGM interviewed and sexual act. 32 of the 40 men were or had been married. examined 4024 women attending the obstetrics and Of these, 25 said they did enjoy sexual intercourse with gynaecology outpatients clinics of a Khartoum hospital their wives, while 7 only partially enjoyed it. 12 of the between 1962 and 1966. Of the total sample, 3013 had 32 who enjoyed sex believed their wives enjoyed it to, 6 type I11 FGM, 807 had type 11, and 204 were unexcised. were aware that their wives hated sex with them, and Among the women with the most extreme form of 14 did not know how their wives felt. In another study FGM, penetration during sexual intercourse had been from Somalia, 15% of the women with type I11 FGM impossible in 4% of cases, though there is no in a sample of 300 women never enjoyed sexual indication how long this condition lasted or how it was relations. And in a study from Ghana, 12% of 76 resolved. Questioned about their sexual response, 84% women who had been excised, mostly type 1/11, did not of women with type I11 said they never had orgasm, experience orgasm, while none of the 119 women in compared with 12% of those with type I1 and 7% of the sample who had not been excised reported failure those without FGM. However, 6% of those with type to reach orgasm. I11 said they experienced orgasm on more than 50% of Several of the large surveys from Sudan explore the occasions, compared with 37% of those with type I1 psychosexual consequences of FGM. One, involving and 30% of those without FGM. Eighty of the 3013 3210 women and 1545 men, found that 81% of the women with type I11 claimed not to know that women women and over 13% of the men had been fearful of can get satisfaction from intercourse and had no idea first sexual intercourse. The majority of them claimed about orgasm. FGM as the reason for their fear. The report does not Information was sought also from 300 men who all correlate fear with type of FGM experienced by the had one wife with type I11 and at least one wife with FEMALE GENITAL MUTILATION l A HANDBOOK FOR FRONTLINE WORKERS 1 3 1 1
type I or no FGM. Sixty of the 300 had married second possible with wives with type 111. Only 34 of the 300 wives expressly because they could not bear the ordeal men mentioned that sex was better with a woman who of struggling to penetrate the increasingly tough scar had type I11 FGM. 90 of the 300 believed their wives of wives with the most extreme form of FGM. 266 with type I11 FGM suffered a great deal of pain and (89%) of them said they preferred sex with wives less never experienced orgasm during intercourse. It is mutilated or not mutilated at all, because they could clear from the studies that men as well as women can enjoy mutual desire and pleasure which was not suffer sexual dysfunction as a result of FGM
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The woman had been married at the age of 14. On her wedding night her new husband had used a knife for de-infibulation. But she had resisted, and her legs were cut in the struggle. She had developed a fever and was hospitalized for a week. She talks about always being fearful of sex and having no enjoyment. She submitted to intercourse in order to have children. But each of her six pregnancies resulted in prolonged labour of up to two days, and infection following the births.
A second case study, of a 32 year old woman with type Ill FGM, tells of her terrible fear on her wedding night. She refused to cooperate with her new husband as he tried to penetrate her vagina, obstructed by keloid scars, with his penis, and was forced eventually to go to hospital for de-infibulation. She developed an infection following the hospital operation. She always hated her husband and finally divorced him. Married to a second husband, she said she was happy with him but rarely enjoyed sex because of her bad
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KEY POINTS
Not all women will have personal FGM is mostly remembered as an extremely experience of any particular health traumatic event that leaves an emotional -, 5" ?""'. J;..;. problem, or combination of problems. scar for life. Information campaigns that focus only on
health issues risk losing credibility with Apart from the direct trauma of the event .' their target audiences unless this is and its psychological effects, FGM works at a acknowledged, and complications put into more subtle level to shape the self-perceptior :- $,J,>..y,f$+ >, ,% 4 some kind of perspective. ~+',,~.;:-~f;i?~,sCbfa. and self-esteem of the young girl. l+ !+l :, ;7;;s,A,;:J . :i& t.ij .: " ,'i ' ;:?:s'Pr~ ;, bts , q ,La, L~~j~'~$~~$v,~s.t-~rvr'~,: > (24%:) kn!$;..i.-. The type and timing of FGM - ie. the age at .$:A' Men as well as women can suffer *itp, 8, which it is carried out - have a bearing on dysfunction as a result of FGM. C the outcome. FGM is not just a health issue for Women may be unaware that the health women, but a human rights issue problems they suffer are the result of FGM, Campaigns should address both aspects of ; attributing them instead to some other, the practice at the same time. perhaps supernatural, cause.